Wednesday, June 18, 2008

Dinosaurs Roam the Earth Once More

The AMA House of Delegates had a chance to make history, but they flinched. Faced with their own ethics council’s recommendation to declare industry funded CME unethical, they had three choices: approve, reject, or delay. They chose to delay, referring the proposal back to committee.

While MECC websites crowed victory, in fact, this is not really their victory at all. The proposal will return. It will be tweaked to become less objectionable to some, and will be resubmitted in November or next June.

Yes, the medical dinosaurs are prowling the earth once more, and that crashing sound through the jungle is heard nowhere louder than in the editorial offices of Medscape, where George Lundberg, their editor in chief, released one of the more bizarre performances in recent memory. In this videotorial, Lundberg declares that CME is “under siege.” Consumer warning: if you watch this, be prepared to cringe.

Like a cornered animal, Lundberg widly lashes out at all progressive forces in medicine, including, in no logical order: Jerome Kassirer, the American Association of Medical Colleges, Jordan Cohen, the American Medical Students Association, the AMA’s Ethics Council, the Josiah Macy Foundation, Senator Charles Grassley, and even JAMA, the journal which Dr. Lundberg once edited. All of these individuals and institutions are part of the vast conspiracy to destroy continuing medical education. What irked me, though (aside from his failure to mention me in his Rogue’s Gallery) were his parting comments: “What does all this mean for Medscape and eMedicine, the largest single source of CE for health professionals? We are just going to keep doing what we are doing. It is good. We are clean. Our work is transparent.”

Good? Clean? Transparent? Are we still talking about Medscape, the discredited purveyor of drug company ads, disguised as CME?

In a prior post, I deconstructed this offering funded by Janssen in which good, clean, and transparent Medscape editors scoured the ends of the earth for the single case study that might make Invega look good—and then created a CME article out of it.

Lundberg’s preposterous opinion piece prompted me to dig a little more deeply into their CME, and it gets worse. Let’s go down the list of their industry-supported CME (there are a few token non-industry funded articles sprinkled in here too). We’ll start with New Data in the Recognition and Management of Bipolar Disorder, an article funded by Lilly, which mentions their Symbyax (a combination of Prozac and Zyprexa) over and over again. When Lilly funds a CME, the editors know exactly what they are paid to do: discuss Zyprexa in a way that downplays its infamous metabolic dangers. True to form, here is the only discussion of weight issues in this article:

“Dr. Thase: Well, the good news on both OFC [Symbyax] and quetiapine is that they do not cause switching, do not induce cycling, and the primary metabolic consequence is weight gain, which is very reliably, accurately measured sequentially and you see it coming. No one will gain 5 kg without first gaining 2 kg, and particularly when they're warned ahead of time. So I would say 1 thing for the interest of primary care prescriber would be to gain some comfort with at least these 2 members of the atypical antipsychotic class, engage the patient in collaborative care and follow-up, watch weight gain closely.The diabetes risk independent of weight gain is rare. It does happen, but you will need to treat well more 100 patients before you actually see someone who develops new-onset diabetes out of the blue, so it is a real consequence, but a rare one and the dyslipidemia is almost entirely weight dependent. So if there is no weight gain, there will be no dyslipidemia.”

This is the gentlest discussion of Zyprexa’s side effects that I’ve ever seen. The activity is ostensibly a discussion between luminaries in psychiatry, and I’m sure that’s how it began. But the editors can cut and paste interviews to achieve a variety of results--I should know, because I do this every month for my own CME newsletter. When I edit my interviews, I do so for clarity and conciseness—but when Medscape edits, they do so to push the sponsor’s product.

Lundberg: “We are good. We are clean. We are transparent.”

Next up: “The Evolving Management Paradigms for Pediatric ADHD.” There isn’t even an effort to provide the illusion of balance in this CME article. It quite simply a parade of praise for Shire products. After the introduction, ten of the first ten slides on treatment are advertisements for Shire products, in this order: Vyvanse (two slides), Focalin (two), Daytrana (three), and Guanfacine XR (three). How will Medscape defend the integrity of this article to ACCME? They will say that the article’s focus is on new ADHD treatments, and it just so happens that Shire has produced them all. It’s a beautifully-honed method of turning CME into promotion while skirting regulations. “It’s not biased—we just chose a topic that inevitably makes our sponsor’s products shine.”

If you keep going down the list, you’ll see the same pattern. Each CME article is biased in favor of the sponsor’s product.

Note to Dr. Lundberg and Medscape: what you are doing is not clean, not good, and most definitely not transparent.

17 comments:

Sara
said...

The sad part of what you are describing, as I see it, is that these doctors totally believe in what they are saying and doing. It would almost be better if it was deliberately dishonest. It's more insidious when the perps actually believe they are doing something "right." This is classic brainwashing and narcissism. It's scary.

Daniel - I certainly appreciate your interest in protecting physicians from hidden messaging and bias. But I must let you know that George Lundberg is not your enemy but your friend in this battle.

I used to work with George at the Medscape Journal, and I can tell you that there was no industry influence on what I did whatsoever. I worked meticulously to disclose any author's conflicts of interest, and we never received a penny of direct funding for any content in the journal. Also note that the majority of Medscape's CME is unsponsored.

If there are indeed sponsored CME articles on Medscape that demonstrate clear bias - then I'm sure that George would be the first to agree to correct and/or remove them from the site.

George is a thoughtful and ethical person - he is transparent, and understands where conflicts lie on many fronts. Let's engage him in a positive way to move medical education forward in as objective a manner as possible.

Speaking of dinosaurs, I just recieved this month's edition of Current Psychiatry. Dr. Nasrallah is polling psychiatrists to find out what is ailing the psychiatric profession. It seems that he left out any mention of commercial influences on research or medical education. Unintentional I'm sure...

It appears that the majority of physicians are clearly behind the curve on this issue. If it was only a concern for the small handful of us who zealously ruminate about it in the blogosphere, then it probably would never gain any traction. However, there is growing public resentment that will ultimately force the medical profession to clean up it's act.

You may be right, but for a "friend" of those seeking the right distance from drug industry marketing, Dr. Lundberg certainly came out with his guns a-blazing. I think he came across as sanctimonious and pompous. Not knowing him personally, perhaps he was just having a bad day. But I stand by my criticisms. If he is going to put himself in the public eye as the representative of Medscape, he needs to hear about the level of corruption that he is defending. I do hope he will take a look at the Psychiatry CME area and insist on reforms.

Hi Daniel - I appreciate your response. I think what George was trying to say is that the conflicts of interest in the CME business are very complicated and there may be some unrecognized hypocrisy at play.

George argues that one doesn’t have to be an academic center or non-profit organization to operate ethically. He gives some examples of how major professional societies and academic centers can create rules to favor themselves and also mishandle CME even while claiming to follow ethical guidelines. He shows how hypocritical it is for organizations to condemn sponsored CME but still accept funding for targeted ad messages from those same sponsors.

George is saying that Medscape is was it is (a for-profit business), but that doesn’t mean it can’t operate with honesty and integrity. If there is a narrow range of content that they botched – they will fix it. But let’s not forget that the majority of what they do really is editorially uninfluenced by sponsorship.

If he seems stodgy that’s unfortunate. Because the man I know is anything but – and the neatest thing about George is that I can honestly say that he was the most fair and unbiased boss I’ve ever had. You should meet him in person some time. He’s a great guy and shares your passion for transparency and high ethical principles. Maybe that's why he got emotional about the issue - because he really cares. ;)

I have become rather polemical on this issue, because, like Dr. Lundberg, it's something I care deeply about. I can agree that those academic medical centers accepting industry sponsorship for CME have no right to take the moral high ground over MECCs. In my experience, however, MECCs produce more blatantly commercial CME than AMCs, probably because they are far more dependent on industry sources of income than AMCs.

But regarding your opinion that most of Medscape's content is "editorially uninfluenced by sponsorship," this is an empirical question. I can't accurately scrutinize their CME offerings in say, cardiology or endocrinology, but on casual inpection they are as saturated with industry sponsorship as the psychiatry section. Hopefully, there's a cardiologist and an endocrinologist out there who has the time to put the "biascope" up to those activities as I have done in psychiatry.

"Like a corned animal" is undignified and over-the-top. Compelling criticism can be made without vituperation.

Replying to this blog's post entitled "Medscape's CME Corruption" (Friday, June 13, 2008) James La Rossa wrote in part, "As a member of the Medscape Publisher's Circle, I have worked with the company for a number of years...I have been consistently impressed with their level of professionalism and expertise. If bogus reader surveys and a new focus on industry-specific CME are emerging trends, as you well quantify, I hope Medscape will take this to heart and re-think its operating procedure.... Thank you for bringing this to our attention."

In his video editorial, “Responding to the American Siege Against Continuing Medical Education”, posted June 12, 2008, available at _http://journal.medscape.com/viewarticle/575699_, Dr. Lundberg stated, "We welcome analysis and criticism."

I hope that Jim La Rossa will be able to inform this blog of Medscape's response to Dr. Carlat's analysis and criticism.

Disclosure: This time I disclose only that I am a patient who wants his physicians to get good quality CME that helps them decide wisely in prescribing medications.

In a recent, related posting, a science writer who authors CME programs for industry, Michael S Altus, PhD, asked a question which goes to the heart of the CME debate. That is -- Who has the MORAL AUTHORITY to provide "clean" and "transparent" continuing education, in the words of George D. Lundberg, MD? At the risk of being redundant, my humble advice is to apply free market principles to this industry and let the docs decide where to dedicate their CME time. If CME is a choice and not a requirement, then only the best programs will survive -- whether they are sponsored by industry or not.

Neither Medscape, nor the pharma manufacturers are to blame for this problem, so why look to them for a solution? If it is clearly in their best interest to put on "clean and transparent" CME programs, watch how fast they'll work to outdo one another. The ACCME created this monster, not Wyeth or Pfizer or GSK. Let doctors decide for themselves who has "moral authority" and who doesn't. Giving up this right and allowing themselves to be "regulated" was the mistake in the first place.

I did not ask the question about who has the moral authority to provide CME. All I did was to quote without comment Dr. Lundberg’s video editorial. Dr. Carlat posted my comment and then blogged about Dr. Lundberg’s video editorial.

I need to digress about the important distinction between writers and authors. I disclosed that am a freelance medical writer-editor who WRITES [emphasis mine] CME that is sponsored by pharmaceutical companies. You described me as “a science writer who AUTHORS [emphasis mine] CME programs for industry.

Writers and editors like me present material for which authors take responsibility. I know that when the term “ghostwriting” is used, it usually means that a pharmaceutical company, sometimes with a medical education and communication company, authors something, and then shops for a key opinion leader to sign it as author. This process of concealing authors is better known as the unethical practice of ghostauthoring rather than as ghostwriting. It’s a lost cause, however, in correcting the usage.

You probably know that the highly reqarded and often quoted International Committee of Medical Journal Editors (ICMJE; www.icmje lists criteria to be named as an author.

For a discussion of the distinction between ghostwriting and ghostauthoring, see “The Role Of Professional Writers”, Thomson CenterWatch Clinical Trials Today, at _www.clinicaltrialstoday.com/2006/07/the_role_of_pro.html_.

Michael, if I was too loose with my wording, I meant no offense. Nor do I have a problem with "ghostwriters," per se, only with authors who neglect to review the copy that goes out under their byline. Please accept my apologies. Again, I meant no offense to you or your profession, which is very similar to my own. Regards, j.

I for one enjoy Dan's colorful descriptions. His pieces are far more interesting to read than those where the author drones on and on simply repeating the same phrases. When I read a column by Dan, I have some idea of what he is feeling.

Let's not get so sensitive that we water down our discourse too much. I'm not even sure what "name calling" really is. Is referring to someone as "goody two shoes" name calling? Is it name calling to compare one's behavior to a cornered animal? I don't know, I guess it is in the eye of the beholder.

I know this much: When people put themselves out there in public, they know going in that they will be judged by others. I think that they expect it and can handle it.

However, a quick stop on Fox News reminds us that there are limits and that crude insults really are not effective.

Dr carlat, this posting was one of your best in the last few weeks. I am home from my mini sabbatical and perused through the last week of things, and felt you were totally on the mark on this piece.

Dr Lundberg is another example of someone who had a soul and lost it in the process of dealing with big pharma. I read his book a few years ago, and when I found out he was involved with Medscape, I just couldn't understand it.

As I have said before, you bargain with the devil, you get burned. Check out the article in the Baltimore Sun this past week,(around the 17th I think, I read it at the beach and there it stayed) at www.baltimoresun.com regarding the role of big pharma trying to squash generics. Sick stuff folks.

While certainly not a blanket defense of George Lundberg, MD, please recall that in 1999, Lundberg was ousted as editor of JAMA after publishing an article which examined the increase in oral sex among teenage girls which was attributable to their mistaken belief that this behavior did not put them at risk for HIV. Following the publishing of that article, the AMA "Leadership" purged Lundberg from the editorship because they felt the publication was politically motivated due to the then-ongoing Clinton/Lewinsky scandal. Soon thereafter, other publications (including ours) confirmed that Lundberg and JAMA was right on target and public attention was focused on this burgeoning health crisis. In my opinion, what happened to Lundberg was one of the most unjust chapters in all of medical publishing. It should be of little doubt why he threw his hat thereafter in the private sector with Medscape Web/MD.

Just something to keep in mind as this important new debate rages on. Best, j.

I believe Mr. LaRossa once published a journal edited by Dr. Nemeroff, and that he authored a piece about Dr. Nemeroff titled "Boss of Bosses." It sheds light on why Dr. Nemeroff is viewed as the Tom DeLay of psychiatry.

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About Dr. Carlat

I am a psychiatrist in Newburyport, Massachusetts and an Associate Clinical Professor of Psychiatry at Tufts Medical School (but note that the opinions expressed in this blog are not those of Tufts). I graduated from the psychiatric residency at Massachusetts General Hospital in 1995, and am the founder and publisher of three CME newsletters, including The Carlat Psychiatry Report. In March 2012, I left the publishing world to work on conflict of interest issues for The Pew Charitable Trusts, as director of the Pew Prescription Project. I returned to Newburyport and Carlat Publishing in September 2014.